? Review Differential Diagnosis
? Case-Based Review
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History ? Important Points? Mass itself:
? Duration, ? Size or character change since noticed
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? Associated symptoms:
? Pain, sensory loss, epistaxis, dysphagia, hoarseness,
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hemoptysis, cold/heat intolerance, hearing change...? Social history:
? Smoking, chewing tobacco, alcohol
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? Past medical history
? Radiation*, skin cancer/lesion
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? Family history *Physical Examination
? Take the time to be thorough
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? Inspection:
? Exterior scalp, face, ear
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? oropharnyx, hypopharnyx, larynx, nasal passage? External Ear
? Flexible fiberoptic endoscopy
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? Palpation -- External & Bimanual
? Mass, thyroid, lymph node levels, oropharnyx,
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salivary glands? Relation to swallowing/tongue protrusion
Fine Needle Aspiration
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? Often the first diagnostic test? Simple and highly sensitive
? No longer felt to risk spread of tumor
? Technically demanding sometimes *
? Don't forget US guidance can be helpful
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? Cytopathologist is keyLab Tests & Imaging
? Play a smaller role than usual
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? Blood work?? C.T. scanning
? Large/complicated mass
? ? Remote primary
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Differential Diagnosis Simplified? Congenital Lesions *
? Salivary Gland Lesions *
? Thyroid Gland Lesions *
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? Lymph Nodes *Triangles
of the
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Neck
Anterior
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SubmandibularSubmental
Carotid
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Posterior
Triangles of the Neck
? Anterior
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? Submandibular
? Submandibular gland
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? Submental? Dermoid, ranula
? Carotid
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? Branchial cleft cyst, Carotid Body Tumour
? Posterior
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? Lipoma, Neurogenic tumor? * Lymph node lesions can be anywhere *
Lymph Nodes
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? Inflammatory
? Lymphoma
? Metastatic
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? Site of the node can help localize the primary? Supraclavicular nodes can be non head & neck 10
? Breast & Lung most common
? GI tract, Prostate, Testicular
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? Eponym*Lymph
Node
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LevelsMemorial
Sloan-
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Kettering
Lymph Node Level
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Likely Primary SiteCases
7 Year Old Boy
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? Small lump middle of neck
? Asymptomatic
? Otherwise healthy
? Physical
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? 1.5cm, firm lump middle neck
? Moves up with tongue protrusion
? What now?
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? ? FNA ? Eponym
65 Year Old Man
? Asymptomatic 2 cm lump Right submandibular
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triangle
? Chews tobacco, no EtOH
? Remainder history negative
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? Physical? 2 cm firm lump ? Submandibular gland on Bimanual
? Remainder negative
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? FNA ? Mucoepidermoid Ca? What now?
38 year old Woman
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? Asymptomatic? Referred by GP for neck nodes
? History entirely negative
? Physical
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? Multiple nodes levels 3 & 4 Right side? Small nodule Right Thyroid
? Likely Diagnosis?
? FNA ? Papillary Ca
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? What now?56 Year Old Man
? Asymptomatic Lump Left Neck
? Heavy Smoker, occasional EtOH
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? No past history or family history? Physical Exam
? Hard lump L neck anterior triangle
? Otherwise negative despite being thorough
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? FNA ? Squamous Cell Carcinoma
? What Now?
A 43-year old man notes shortness of breath. He
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is a non smoker. His wife points out that his face
has become slightly swollen. On examination, his
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blood pressure is normal. His pupils are equal andrespond to light. Dilated veins are noted around
the shoulders, upper chest, and face. An x-ray of
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the chest reveals an opacity in the superior
mediastinum. What is the most likely diagnosis?
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(A) Thymoma(B) Neurogenic tumor
(C) Lymphoma
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(D) Teratodermoid tumor
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This 19 year old girl had a
two-week history of a
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painless swelling in the leftjugulo digastric region.
FNAC demonstrated benign
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squamous cells, cellular
debris and cholesterol
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crystals. CT scandemonstrated a well
circumscribed cystic mass,
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anterior to the
sternomastoid muscle. This
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is a typical ?This young woman had a
one-week history of a
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rapidly enlarging mass in
the upper right neck with
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localised tenderness. TheCT scan again
demonstrates a well
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circumscribed unilocular
cyst, with a smooth wall
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This young man has a
prominent painless lymph node
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in the jugulodigastric region.Fine needle aspiration biopsy
indicated a diagnosis of
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Hodgkin's Disease. The 40
year old man (inset) has a lump
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in an identical position, alsopainless and present for months.
Fine needle aspiration biopsy
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confirmed the diagnosis of
metastatic squamous cell
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carcinoma from a tonsil cancer.He was a non smoker.
The man is 60, a heavy smoker
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and presents with a hoarse
voice and large mass in the
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right upper neck. Fine needleaspiration biopsy showed
necrotic debris and the CT scan
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demonstrates a unilocular
cystic mass. The cyst wall is
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irregular and this is metastaticsquamous carcinoma, which
has undergone cystic
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degeneration. The primary
cancer was in the hypopharynx
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This man has
nasopharyngeal carcinoma
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with multiple metastaticlymph nodes in the
posterior triangle,
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bounded by the clavicle
below, sternomastoid
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muscle anteriorly and thetrapezius posteriorly..
The young man had a
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firm, but not hard
submandibular swelling
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which had been presentfor 5 years. The CT scan
on the right demonstrates
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a midline dermoid cyst.
This is a well localised
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benign congenital lesion.This young woman, aged
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25, has a well localisedswelling just below the
hyoid bone, which elevates
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on protrusion of the tongue.
The CT scan on the right is
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from another patient butdemonstrates identical
pathology of a well
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circumscribed cystic
structure lying anterior to
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the thyroid cartilage -thyroglossal cyst.
This young woman has a
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prominent right thyroid
nodule. The appropriate
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investigations are FNABand serum TSH.
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This boy, aged 14,
presented with a cystic mass
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in the left submandibular
region. Needle biopsy
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demonstrated the presenceof mucoid material and the
CT scan shows a cystic
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mass lying anterior to the
left submandibular salivary
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gland. This is a typicalplunging ranula and is due
to extravasation of mucoid
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saliva from the sublingual
gland
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This elderly man has alarge left submandibular
mass. An SCC of the
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cheek was removed a year
earlier. FNAB showed
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metastatic SCC and theCT scan demonstrates a
large cystic mass with a
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septum, consistent with
metastatic cancer.
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This 45 year old Asian
woman, recently migrated
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to Australia, presentedwith a supurating mass in
the right submandibular
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region. A diagnosis of
tuberculosis was made
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following culture of tissuefrom the mass
Questions/Comments
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